Nurse AnesthesiaA Past, Present, and Future Perspective

Wanda O. Wilson, CRNA, PhD, MSN

KEYWORDS

� Anesthesia � CRNAs � Health care reform � Advanced practice registered nurse

KEY POINTS

� The US health system is rapidly reaching a point at which inefficient use of resources andduplication of efforts cannot be sustained.

� The Institute of Medicine’s 2010 report on the “Future of Nursing” clearly identified thatthe United States needs to examine how to make best use of highly qualified advancedpractice registered nurses (APRNs) to drive a more efficient and effective health caresystem.

� Certified registered nurse anesthetists (CRNAs) will help manage this change bycontinuing to provide patient access to safe, cost-effective anesthesia care; knowingthe direction in which health care is headed; being politically active at the state andfederal levels; educating the public about the value of nurse anesthetists; and beinginvolved at the local community and institutional levels.

The health care specialty of nurse anesthesia was born amid the battlefields of theAmerican Civil War.In 2012, some 150 years later, more than 44,000 CRNAs and student registered

nurse anesthetists across the United States will administer approximately 32 millionanesthetics to patients in every type of practice setting in which anesthesia is required.In addition, in testament to the profession’s roots, today’s nurse anesthetists remainthe primary anesthesia caregivers to US service men and women at home and abroad.Throughout their history, nurse anesthetists have prevailed over challenges from

organized medicine and others who have sought to limit their scope of practice andreduce patient access to their services. Similar challenges lie ahead as the overbur-dened US health system turns to APNs and other specialists who are not medicaldoctors (MDs) or doctors of osteopathy (DOs), to fulfill a larger role in providingsafe, cost-effective health care services to an aging patient population. Answeringthe call just as their forebears did during anesthesia’s formative years, today’s nurseanesthetists have embraced the responsibility of helping meet America’s growing

Dedicated to John F. Garde, CRNA, MS, FAAN.American Association of Nurse Anesthetists, 222 South Prospect Avenue, Park Ridge, IL 60068,USAE-mail address: wwilson@aana.com

Nurs Clin N Am 47 (2012) 215–223doi:10.1016/j.cnur.2012.02.010 nursing.theclinics.com0029-6465/12/$ – see front matter � 2012 Elsevier Inc. All rights reserved.

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health care needs as well as the requirement of doctoral education for entry into nurseanesthesia practice by 2025, thereby ensuring patients continued access to the high-est quality anesthesia care possible.This article offers a brief history of nurse anesthesia, assesses the present state of

the profession, and discusses why nurse anesthetists will continue to be an invaluablepart of the US health care system well into the future.

A HISTORY OF MOVING FORWARD

With the discovery of the anesthetizing properties of various drugs during themid–nine-teenth century, the idea of using general anesthesia for surgery gained rapid popularity.However, having noone qualified to administer anesthetic agents, the job of anesthetistwas passed to whoever was available, from house officers to medical students to jani-tors. As a result, anesthesia was cited as the cause of the greatest incidence of surgicalmorbidity and mortality in the late 1800s.As the furor over the high death rate grew, surgeons decided that the major cause of

the adverse effects of anesthesia was the so-called occasional anesthetist, and calledfor clinicians who would dedicate themselves solely to the specialty of anesthesia. InHistory of Anesthesia with Emphasis on the Nurse Specialist (1953), historian VirginiaThatcher identified the reasons why surgeons turned to nurses. According to Thatcher,surgeons “wanted a personwhowould (1) be satisfiedwith the subordinate role that thework required, (2) make anesthesia their one absorbing interest, (3) not look on the situ-ation of anesthetist as one that put them in a position to watch and learn from thesurgeon’s technique, (4) accept relatively low pay, and (5) have the natural aptitudeand intelligence to develop a high level of skill in providing the smooth anesthesiaand relaxation that the surgeon demanded.”The earliest recorded nurse anesthetist was Sister Mary Bernard, a Catholic nun

who administered anesthesia at St. Vincent’s Hospital in Erie, Pennsylvania, in 1877.In the next 10 to 15 years, nurses made great progress as anesthesia providers withthe support of pioneering physicians such as Dr William Worrall Mayo and his son,Dr Charles H. Mayo. Charles shared his father’s belief that nurses were capable ofbecoming fine anesthetists, and in 1893 began working with Alice Magaw, whoearned international respect and was given the title the Mother of Anesthesia byCharles for her outstanding performance and contributions to anesthesia. InDecember 1906, Magaw published “A Review of Over 14,000 Surgical Anesthetics”in Surgery, Gynecology, and Obstetrics. In the article, she reported using chloroformand ether anesthesia with the open-drop technique without a single fatality attribut-able to anesthesia.The Mayo Clinic in Rochester, Minnesota, subsequently became a place where

surgeons sent their nurses to observe and learn anesthesia administration fromMagaw. Nurse anesthetists such as Magaw perfected the technique of using a combi-nation of chloroform and ether by the open-drop method, which satisfied the surgeonsand provided comfort and safety for their patients.Another physician who greatly supported nurse anesthetists was Dr George Wash-

ington Crile at Lakeside Hospital in Cleveland, Ohio. In 1908, Crile asked AgathaHodgins to become his personal anesthetist, and within a year she perfected theadministration of nitrous oxide-oxygen anesthesia. Surgeons who came to observeboth surgery and anesthesia at Lakeside were so impressed by this method of anes-thesia that they asked to have nurses from their own clinics trained by Hodgins.In 1915, on returning to the United States after providing care to wounded soldiers

during World War I, Hodgins and Crile were faced with the first major challenge

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concerning nurses’ rights to administer anesthesia. The Ohio State Medical Boardsent a letter to Crile informing him that it was the board’s decision that no one otherthan a registered physician was permitted to administer anesthesia, and that the stateAttorney General concurred. The board also issued a cease-and-desist order to Crile,stating that, if he continued to use nurses in the administration of anesthesia, LakesideHospital’s School of Nursing would lose its accreditation. It took 2 years for Crile topersuade the medical board to lift the order, and he and Hodgins began educatingnurses in anesthesia once again. Crile and some of his supporters suspected thatthe same challenge could be directed at others; they went to the Ohio legislature toacquire an exemption within the Medical Practice Act for nurses appropriatelyeducated in anesthesia to administer anesthesia under the supervision of a physician.This exemption was achieved in 1919, the first such mention of nurse anesthetists ina state statute.Because of the many accomplishments of America’s nurse anesthetists in front-line

surgical units and hospitals during World War I, the demand for nurse anesthetistsincreased rapidly after the war. As a result, new nurse anesthesia educational pro-grams moved into university hospitals and major community hospitals. During thisperiod of growth for the profession, another serious challenge to nurse anesthesiapractice arose when the Kentucky Medical Society alleged in 1917 that only physi-cians should administer anesthesia. With the concurrence of the state AttorneyGeneral, the society issued an ethical policy that sanctioned by expulsion any memberof the society who used nurse anesthetists or practiced in hospitals that employednurse anesthetists. Dr Louis Frank, a Louisville surgeon, and his nurse anesthetist,Margaret Hatfield, along with the Kentucky State Department of Health, filed suitagainst the society. Frank and Hatfield won at the appellate level, with the justice rulingthat Hatfield was not practicing medicine in the way and under the circumstances inwhich she was administering anesthesia (Frank et al v. South et al, Kentucky Rep.175:416–428).The last significant court challenge on the subject of whether nurse anesthetists

were practicing medicine came between 1933 and 1936, when Dagmar Nelson wascharged by some physician anesthetists with such practice. Although the case wentall the way to the California Supreme Court, favorable rulings for Nelson were renderedat each level (Chalmers-Francis et al v. Nelson et al (Calif) 57 P(2d) 1312).Many important advances in practice rights and patient safety have been made by

nurse anesthetists through the years, and although unnecessary challenges by themedical community have persisted, CRNAs and their professional organization, theAmerican Association of Nurse Anesthetists (AANA), have been equally persistent infending them off. In Bahn v NME Hospitals (1985), the US Circuit Court of Appealsruled that, under certain circumstances, CRNAs working with physicians other thananesthesiologists can compete with anesthesiologists and thus have standing to bringa federal antitrust suit under circumstances prescribed in antitrust law. Nearly 2decades later, in 2004, the Minnesota Association of Nurse Anesthetists (MANA)successfully resolved legal actions brought by MANA on behalf of the Federal Govern-ment against hospitals and anesthesiologists alleging wrongful termination of nurses,antitrust violations, and Medicare fraud. The lawsuit, which took 10 years to run itscourse, was instrumental in bringing about substantial regulatory changes regardingreimbursement of CRNAs and anesthesia professionals generally. Between these 2important cases, Medicare direct reimbursement legislation for CRNAs was signedinto law by President Ronald Reagan in 1986, making nurse anesthesia the firstnursing specialty to be accorded direct reimbursement rights under this federalprogram.

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NURSE ANESTHESIA IN THE TWENTY-FIRST CENTURY: SAFE, COST-EFFECTIVEANESTHESIA CARE

The AANA today represents a profession that is more than 44,000 strong, includingCRNAs and student registered nurse anesthetists. These APNs serve in variouscapacities in their daily practices, taking on roles of clinician, educator, administrator,manager, researcher, and consultant. The AANA establishes evidence-based profes-sional standards of anesthesia care and guidelines for nurse anesthesia practice thatare updated frequently, published in the Professional Practice Manual, and can befound online at www.aana.com.CRNAs administer anesthesia for all types of surgical cases, use all anesthetic tech-

niques, and practice in every setting in which anesthesia is delivered, including tradi-tional hospital surgical suites and obstetric delivery rooms; critical access hospitals;ambulatory surgical centers; the offices of dentists, podiatrists, ophthalmologists,plastic surgeons, and pain management specialists; and US military, Public HealthServices, and Department of Veterans Affairs health care facilities. They provide anes-thesia in collaboration with surgeons, anesthesiologists, dentists, podiatrists, andother qualified health care professionals. When anesthesia is administered by a nurseanesthetist, it is recognized as the practice of nursing; when administered by an anes-thesiologist, it is recognized as the practice of medicine. Regardless of whether theireducational background is in nursing or medicine, all anesthesia professionals giveanesthesia the same way. CRNAs provide services as employees of hospitals orphysicians or as private practitioners either by clinical privileging and/or as contrac-tors; the average annual compensation for a CRNA is approximately $160,000.CRNAs are the sole anesthesia professionals in most rural hospitals in the United

States, and, in some states, are the sole anesthesia professionals in nearly 100% ofrural facilities. CRNAs also provide a significant percentage of anesthesia care in innercities and other medically underserved areas of the United States, affording patients inthese areas access to essential surgical, obstetric, trauma stabilization, and painmanagement services.

Landmark Studies Confirm CRNA Safety and Cost-Effectiveness

At the turn of this century, major regulatory events were taking place that wouldprofoundly change the health care landscape for nurse anesthetists and their patients.In 1997, the Health Care Financing Administration (HCFA; now the Centers for Medi-care & Medicaid Services [CMS]) of the Department of Health and Human Servicesreleased a proposed rule to defer to the states on physician supervision of CRNAsfor Medicare cases. With the announcement, the AANA made this its top legislativeand regulatory priority, as did the American Society of Anesthesiologists (ASA), whichwas determined to prevent the removal of this outdated reimbursement requirement.The issue was vigorously debated in Washington, DC, state capitals, and the media for3 years before the HCFA announced in 2000 that it would finalize the rule removing thefederal requirement and deferring to the states on physician supervision of CRNAs forMedicare cases. Because the rule was published in the Federal Register in the lastdays of the Clinton administration, it was delayed by the new Bush administrationand reconsidered. Subsequently, a different rule was published in November 2001that kept in place the Medicare requirement of physician supervision of CRNAs whileestablishing a process by which state governors could write to CMS to opt out of therequirement. Less than 1 month after finalization of the supervision opt-out rule, Iowabecame the first state to take advantage of the opportunity to remove the physiciansupervision requirement for nurse anesthetists working in that state. Since then,

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15 states have followed Iowa’s lead, bringing to 16 the number of states that no longerrequire physician supervision of nurse anesthetists.When the final rule was published, CMS expressed interest in an eventual study

on anesthesia safety in the states where physician supervision was no longer required.Nine years later, in 2010, researchers from RTI International examined nearly 500,000individual Medicare cases in the first 14 opt-out states and concluded that “there areno differences in patient outcomes when anesthesia services are provided by CertifiedRegistered Nurse Anesthetists (CRNAs), physician anesthesiologists, or CRNAssupervised by physicians.” This landmark study, titled “No Harm Found When NurseAnesthetists Work Without Supervision by Physicians,” was published in the Augustissue of Health Affairs. Also in 2010, another important study, this one conductedby The Lewin Group and published in the Journal of Nursing Economic$, determinedthat a CRNA “acting as the sole anesthesia provider is the most cost effective model ofanesthesia delivery.” This study, titled “Cost Effectiveness Analysis of AnesthesiaProviders,” considered the different anesthesia delivery models in use in the UnitedStates today, including CRNAs acting solo, physician anesthesiologists acting solo,and various models in which a single anesthesiologist directs or supervises 1 to 6CRNAs. The results showed that CRNAs acting as the sole anesthesia provider cost25% less than the second lowest cost model. The Lewin researchers also conducteda thorough review of the literature that compares the quality of anesthesia service byprovider type or delivery model, and determined that the published studies show thatthere are no measurable differences in the quality of care between CRNAs and anes-thesiologists or by delivery model.Despite the important contributions to the US health care system that nurse anes-

thetists have made for 150 years, and research evidence that validates their record ofsafety and cost-effectiveness, attempts by organizedmedicine to discredit the profes-sion and restrict CRNA practice rights continue to the present day.

Educational Requirements for Becoming a CRNA: Today and Tomorrow

Since 1998, all nurse anesthetists have been required to complete a rigorous, focusedcourse of graduate-level education resulting in a master’s degree; many members ofthe profession have gone on to pursue doctorate degrees, including the PhD. In 2007,the AANA announced its support of doctoral education for entry into nurse anesthesiapractice by 2025, propelling nurse anesthetists to yet another level of preparedness onbehalf of the patients they serve.As of January 2012, the requirements for an individual to become a CRNA andmain-

tain that status include the following:

� ABachelor of Science inNursing (BSN) or other appropriate baccalaureate degree� A current license as a registered nurse� At least 1 year of experience as a registered nurse in an acute care setting� Graduation with a minimum of a master’s degree from an accredited nurse anes-thesia educational program

� Pass the national certification examination following graduation� In order to be recertified, CRNAs must obtain a minimum of 40 hours of approvedcontinuing education every 2 years, document substantial anesthesia practice,maintain current state licensure, and certify that they have not developed anyconditions that could adversely affect their ability to practice anesthesia.

Nurse anesthesia education builds on prior nursing education and experience. Theminimum curriculum incorporates studies in basic and advanced applied sciences aswell as principles and professional aspects of nurse anesthesia. Because these

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programs usually exist in colleges of nursing or allied health or schools of medicine,differing curricular requirements round out the course content based on the particularrequirement of the department, school, or college in which they are located. Mostprograms require research, and many require completion of a project or thesis forgraduation.Nurse anesthesia educational programs are 24 to 36 months in length, and confer

a master’s degree on successful completion. These programs provide an education-ally sound curriculum combining theory and clinical practice. Within the clinicalcomponent, each student is required to administer a minimum number of anestheticagents to patients and work a minimum number of hours of anesthesia time. Tomeet these requirements, students provide the anesthesia services under the super-vision of qualified clinical instructors, including CRNAs and/or anesthesiologists.CRNAs are prepared to administer all types of anesthesia (general, regional, local,

and conscious sedation), use all anesthesia and adjunctive drugs, determine needfor and manage fluid and blood therapy, monitor and interpret data from sophisticatedmonitoring devices, insert invasive catheters (intravenous, central venous, and pulmo-nary artery catheters), recognize and correct complications that occur during thecourse of anesthesia, provide airway and ventilatory support, manage resuscitationefforts for cardiopulmonary arrest or serious injury, and provide pain managementservices.Although the AANA had long discussed the possibility of nurse anesthesia educa-

tion transitioning to the doctorate, the concept took on a different emphasis in 2004when the American Association of Colleges of Nursing (AACN) published a positionstatement on the doctorate in nursing practice that addressed transformationalchange in the education required for entry into advanced nursing practice. Titled“Position Statement on the Practice Doctorate in Nursing,” the AACN envisioneda practice doctorate requirement for all advanced practice nurses (APNs) for entryinto practice by 2015. CRNAs were identified in the cadre of APNs.Nurse anesthesia educational requirements have advanced significantly since Aga-

tha Hodgins and her colleagues founded the AANA in 1931. Early on, the professionidentified a primary objective to develop standards for nurse anesthesia education;over the years these standards for nurse anesthesia programs have evolved tomeet the required knowledge and skills for entry into practice. In the 1980s, nurseanesthesia educational programs moved from hospital-based certificate programsto university-based graduate programs, and, in 1998, the Council on Accreditationof Nurse Anesthesia Educational Programs (COA) finalized the requirement that allprograms award a master’s or higher-level degree.From the mid-1980s to the late 1990s, the AANA and the COA periodically

assessed the need for, and feasibility of, practice-oriented doctoral degrees for nurseanesthetists. After the AACN adopted its position statement in October 2004, theAANA Board of Directors convened an invitational summit meeting of stakeholdersin June 2005 to discuss interests and concerns surrounding doctoral preparationfor nurse anesthetists. Pursuant to the summit meeting and with the approval ofthe Board of Directors, a Task Force on Doctoral Preparation of Nurse Anesthetists(DTF) was appointed. The DTF was charged with developing options relative todoctoral preparation of nurse anesthetists that the AANA Board could consider. Toaccomplish this, the task force held numerous meetings, conducted surveys, andheld open hearings at AANA national meetings. The DTF’s final report and optionswere presented to the board in April 2007. After much dialogue and debate, theAANA announced its support for doctoral education for entry into nurse anesthesiapractice by 2025. The AANA Position on Doctoral Preparation of Nurse Anesthetists

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was announced to the membership in August 2007, with the following rationale forthe decision presented:

� AANA has advanced quality education� CRNAs are prepared safe providers� To best position CRNAs to meet ongoing challenges and remain recognizedanesthesia leaders.

When the AANA was founded more than 80 years ago, one of the basic tenets fororganizing was so that the association would advance quality education as the meansto ensure that nurse anesthetists are the best-prepared, safest anesthesia providerspossible. With today’s health care environment changing at an extraordinary rate,providers are required to keep pace by continually expanding their knowledge baseand skill sets like never before. To best position CRNAs to meet this ongoing challengeand remain recognized leaders in anesthesia care, the AANA thinks it is essential tosupport doctoral education that encompasses technological and pharmaceuticaladvances, informatics, evidence-based practice, systems approaches to qualityimprovement, health care business models, teamwork, public relations, and othersubjects that will shape the future for anesthesia professionals and their patients.The COA was in agreement with the AANA, lending its endorsement to the associ-

ation’s position to require doctoral education for entry into nurse anesthesia practiceby 2025. However, the decision did have opposition. Some in the CRNA communityobjected, arguing that education at the doctoral level for nurse anesthetists wasunnecessary, and that the increased cost of education would result in decreasingapplicants to nurse anesthesia educational programs and ultimately a decline in work-force numbers. The medical community objected to doctoral education for APNs ingeneral, voicing the concern that these specialized nurses would misrepresent them-selves to patients in clinical areas. As the debate escalated, clinical access for nurseanesthesia students became jeopardized at some sites, especially those heavilycontrolled by anesthesiologists. An additional difficulty in the transition to doctoraleducation in nurse anesthesia is that doctoral degree titles vary widely, from Doctorateof Nursing Practice (DNP) to Doctorate of Nurse Anesthesia Practice (DNAP), theresult of approximately 50% of all nurse anesthesia educational programs not residingin colleges of nursing.Despite APN doctorates continuing to provoke debate, particularly within the physi-

cian community, more and more nurse anesthesia educational programs are makingthe transition to doctoral curriculum, and practicing CRNAs are enrolling at doctoralprograms in increasing numbers.

NURSE ANESTHESIA PRACTICE: WHAT THE FUTURE HOLDS

The AANA has been strengthened by and continues to flourish through the dedicationof its members, volunteer leaders, and staff. This dedication will be critically importantgoing forward, because, like all health care professionals, CRNAs are continually facedwith managing change. Ongoing advancements in anesthesia technology, pharma-cology, educational requirements, and practice standards have contributed signifi-cantly to anesthesia today being nearly 50 times safer than it was during the 1980s,regardless of provider type. Such changes for the good are easily managed comparedwith changes that may be perceived to have less favorable potential outcomes. A goodexample of the latter is theObama administration’s health reformplanwith its attendantgovernment wrangling, supply-and-demand economics, and rivalries between orga-nized medicine and other health care professionals.

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What does the future hold for nurse anesthesia? Although it is impossible to seevery far into the future with any clarity, a clear picture of the near future becomesmore visible by the day. Opportunities and challenges lie ahead in numerous areas,first and foremost technology, which keeps changing at a rapid pace. Few thingshighlight the differences between the generations like the ability and desire tokeep up with, and adapt technology to, every facet of daily life. How might thisaffect health care professionals across generations working side by side in the clin-ical setting? Time will tell. In anesthesia, advancements to standard equipment suchas anesthesia machines, monitors, laryngoscopes, and injection devices continue toimprove the quality of patient care, keeping providers of all ages in a continual modeof learning and self-improvement and requiring practice standards and guidelines tobe routinely reviewed and updated. In addition, technology is having a powerfulimpact on direct patient care as less invasive procedures are developed andused, leading to more outpatient procedures, shorter hospital stays, and fasterpatient recovery. The impact on nurse anesthesia has been, and will continue tobe, a gradual migration of CRNAs from the traditional hospital setting to outpatientsettings such as ambulatory surgery centers and physicians’ offices. The develop-ment of robotic systems and artificial intelligence will also advance and the userinterface for these seemingly futuristic tools will become simpler. Traditional ideasabout safe practice will be tested as providers adapt the use of cell phones, iPads,laptops, and other mobile devices to clinical settings, including the operating room:What will ultimately be deemed acceptable and safe, and what will be consideredtaboo? Research evidence will ultimately frame the debates that occur and the deci-sions that get made.In the education of student registered nurse anesthetists, the use of simulation will

continue to develop as a means to impart and validate skills and knowledge withoutexposing patients to the process of clinical education; simulation will likely be usedas part of the application process as well, to help identify and select candidates foradmission to educational programs. Complex simulation will also play a larger rolein the continuing education of certified providers, as Web-based modalities and othertools are used to deliver information and assess competency for practice.Demonstration of health care provider competency will continue to be of paramount

importance to patients, employers, insurers, lawmakers, and others with a vestedinterest in quality assurance. In nurse anesthesia, the movement to doctoral prepara-tion and consideration of enhanced recertification requirements has sparked muchdiscussion within the profession, but there is little doubt that education changes theworld view, and as a body of doctorally prepared CRNAs emerges in the future,how the profession is perceived by its various publics will change for the better.CRNAs will be well prepared to take leadership positions on boards that shape healthcare systems, and to influence accountable care organizations, medical homes, andother entities yet to be envisioned.Downward pressure on health care spending and changes in health care financing

mechanisms intended to increase quality and care coordination while mitigating costgrowthwill shapeCRNApractice and demand for CRNA services. Newmodels of reim-bursement and health care financing will be developed, with movement away fromcapitated payment to fee-for-service and volume-based payment to outcome-basedpayment systems. As these changes evolve, the type of practitioner providing carewill become less important than the result of treatment, further eroding the artificiallydefined scope of practice boundaries. To lower costs, purchasers of health careservices will seek lower-cost professionals and methods of care delivery, which insome circumstances will reduce, and in others increase, demand for CRNA services.

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Increased interprofessional collaboration in health care will be expected, perhapseven mandated, because the US health system is rapidly reaching a point at whichinefficient use of resources and duplication of efforts cannot be sustained and shouldnot be tolerated. The Institute of Medicine’s 2010 report on the “Future of Nursing”clearly identified that the United States needs to carefully consider how to make thebest use of highly qualified APNs to drive a more efficient and effective health caresystem. Collaboration and cooperation across the broad spectrum of health careprofessionals and the organizations that represent them is essential.Howwill CRNAsmanage such change?With the same vigilance, preparation, deter-

mination, knowledge, experience, and ability that serve them so well caring for theirpatients every day. By continuing to provide patient access to safe, cost-effectiveanesthesia care; knowing the direction in which health care is headed; being politicallyactive at the state and federal levels; educating the public about the value of nurseanesthetists; and being involved at the local community and institutional levels,CRNAs will continue to thrive today and in the future.

RESOURCES AND FURTHER READINGS

American Association of Nurse Anesthetists Archives, 222 South Prospect, ParkRidge (IL), 60068–4001.

Certified Registered Nurse Anesthetists (CRNAs) at a glance fact sheet. AANA,August 2011.

Quality of Care in Anesthesia. Park Ridge (IL): AANA; 2009.Bankert M. Watchful care: a history of America’s nurse anesthetists. New York:

Continuum; 1989.Thatcher VS. History of anesthesia with emphasis on the nurse specialist. Philadel-

phia: JB Lippincott; 1953.Advancing the art and science of anesthesia for 75 years: a pictorial history of the

American Association of Nurse Anesthetists. Park Ridge (IL): AANA; 2006.